Kirkwood Manor faces challenges in its CMS ratings, earning a D grade with a score of 40/100. The facility ranks in the 44th percentile among Texas nursing homes, suggesting significant room for improvement.
Staffing at Kirkwood Manor is near the national average, with 3.48 total nursing hours per resident per day (national average: 3.8 hours).
Recent CMS inspections identified 49 deficiencies at Kirkwood Manor, including 1 classified as serious — among the most concerning citation levels. The most notable finding involved: provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist..
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.48 | 3.8 | Average |
| Registered Nurses (RN) | 0.47 | 0.7 | Below Average |
| Licensed Practical Nurses (LPN) | 0.88 | 0.7 | Above Average |
| Certified Nursing Assistants (CNA) | 2.13 | 2.4 | Below Average |
| Weekend Total Nursing | 3.04 | 3.8 | Below Average |
| Weekend RN Hours | 0.30 | 0.7 | Below Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0755 Severity DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Jun 3, 2025 · Pharmacy Service Deficiencies
- Tag 0761 Severity DEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologiJun 3, 2025 · Pharmacy Service Deficiencies
- Tag 0584 Severity EHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for dFeb 20, 2025 · Resident Rights Deficiencies
- Tag 0880 Severity EProvide and implement an infection prevention and control program.Feb 20, 2025 · Infection Control Deficiencies
- Tag 0645 Severity DPASARR screening for Mental disorders or Intellectual DisabilitiesFeb 20, 2025 · Resident Assessment and Care Planning Deficiencies
📊 Resident Outcome Measures
Based on CMS quality measure data. Lower percentages are better for most metrics.
| Measure | This Facility | Nat'l Avg | |
|---|---|---|---|
| Residents with pressure ulcers | 3.4% | 4.5% | Better |
| Falls with major injury | 3.6% | 3.0% | Worse |
| On antipsychotic medication | 5.5% | 14.5% | Better |
| Urinary tract infections | 0.0% | 2.5% | Better |
| ADL decline (daily activities) | 35.2% | 14.0% | Worse |
| Excessive weight loss | 2.5% | 7.5% | Better |
| New/worsened incontinence | 22.4% | 45.0% | Better |
⚠️ Penalties & Fines
1 penalty recorded by CMS
Total fines: $29,026
How This Grade Was Calculated
This facility's grade of D is based on a score of 40 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 2★ → 16 pts (max 40)
- Health Inspection Rating: 2★ → 10 pts (max 25)
- Staffing Rating: 3★ → 12 pts (max 20)
- Quality Measures Rating: 3★ → 9 pts (max 15)
- Penalty deductions: -5 pts
- Fine deductions: -2 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
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